2.0 Analysis 2.1 Impact of Navigational Practices and Safety Navigating personnel are required to employ sound navigational practices aboard their respective vessels. Such practices include maintaining a constant awareness of prevailing circumstances so as to be able to accurately gauge risk of collision with another vessel. To this end, the COLREGS require that a proper look-out be maintained at all times by sight and hearing and using all available means appropriate to the prevailing conditions and circumstances. Both vessels were fitted with working radars. The Jose Narvaez had one of its two radars operating. The information on the radar was not used to advantage, proper radar watch was not maintained, and the wheel-house was left unattended at a critical time prior to the collision. No dedicated look-out was posted and there was higher-than-normal volume of recreational craft transiting the area at the same time as the tug and barge. Cues, both visual and on radar, were available to the tug's navigating personnel but were not used to advantage. No attempt was made to use the VHF for communicating with the approaching vessels. No additional safeguards (such as use of a searchlight trained on the barge, or any other action) taken to warn other vessels (including the Sunboy) that they were running into danger. Given the level of training and experience of the operator of the Sunboy, emphasis was placed on visual navigation to the exclusion of equipment, such as radar, that could have provided additional information. Additionally, the operator of the pleasure craft did not recognize the significance of the pattern of navigation lights displayed by the tug, and consequently was unaware that there was a risk of collision with the tug/tow combination. The situation was further compounded by the low visibility range of the starboard sidelight on board the Texada B.C., which deprived the operator of a vital collision-avoidance cue with respect to the presence and location of the barge. All of the above would indicate that an effective look-out was not maintained by either vessel nor was the risk of collision properly assessed. The maintenance of a proper lookout and the display of a sidelight with the appropriate range of visibility by the Texada B.C. could have given the navigating personnel on board both vessels an opportunity to better appreciate the developing collision situation in ample time to effect remedial measures. 2.2 Navigation Lights 2.2.1 Recognition of Navigation Lights The tug was displaying the required sidelights, three vertically arranged masthead lights, and a yellow towing light above a stern light. The recognition of the masthead lights at the prescribed range of five miles would have given the operator of the Sunboy an opportunity of some 16 minutes to effect collision-avoidance action. Also, recognition of these lights would have indicated to him that the tug was pulling a tow astern, and that the distance between the sterns of the tug and the tow exceeded 200 m. This, in turn, would have alerted the operator of the Sunboy to the danger of passing close astern of the tug. 2.2.2 Visibility Range of Barge Lighting The visibility range of navigation lights is an important factor in maintaining vessel safety. For this reason, sidelight visibility ranges are prescribed by the COLREGS. These international regulations help ensure that mariners can detect nearby vessels and make navigational decisions best suited to safe passage. Vessels that do not display navigation lights, or that display lights with an insufficient visibility range, run the risk of being undetected or of being detected too late to avoid a mishap. The barge's sidelights are required to have a minimum visibility range of three miles. However, an independent laboratory test conducted on the Scotty lantern that was aboard the Texada B.C. showed that on a clear night and with the battery fully charged, the light had a visibility range of less than four cables. On the night of August 7, the visibility was good. According to the laboratory test results, the visibility range of the Scotty lantern, with a green lens having been substituted for its clear lens, would have been, at best, only one tenth of the range required by regulations. Any vessel approaching the barge and relying solely on the barge lighting would have had substantially less time to take timely collision-avoidance action. Neither the occupants of the Sunboy nor others who observed the accident (from other vessels) saw a green sidelight on the barge. The tested visibility range of the barge's starboard sidelight, in conjunction with the closing speed of vessels, would have allowed the operator of the Sunboy one minute to observe and identify the barge and then act to avoid colliding with it. Generally, a sidelight with a visibility range of the prescribed three miles would have given a vessel some 10 minutes to respond to the situation. In this instance the starboard sidelight of the Texada B.C. could only have been sighted once the Sunboy was around Point Atkinson, the distance separating the two vessels being about 2.1 nm. A sidelight, with the required visibility range, would have given the operator of the Sunboy some seven minutes to perform the same procedures. This occurrence highlights the importance of using appropriate navigation lights that can be detected at a range necessary for taking collision-avoidance action. 2.2.3 Widespread Use of Substandard Navigation Lights in the Towing Industry Canada's largest tug boat fleet is located in B.C., where log booms and barges ply the coastal waters in all conditions of visibility, often near commercial and recreational vessels. In a congested area at night, tugs and their tows pose a greater threat to maritime safety than do most other vessels because the cable connecting them lies hidden a short distance below the surface of the water and there is no visible link between the two. A vessel operator who attempts to pass astern of a working tug without being aware of navigation lights displayed by tugs and tows is in danger of colliding with the submerged towline or the towed object. The danger of such an occurrence increases as the visibility range of critical navigation lights aboard the tug or tow decreases. Scotty lanterns, like that tested by the TSB, were manufactured with a maximum visibility range of one mile (using a clear lens). They were marketed and distributed to wholesale and retail suppliers as barge, boom or anchor lights, and subsequently were sold to customers in the industry, who used them as navigation lights. While manufactured as an all-round white light, the light was subsequently modified, for use as a sidelight, by substituting the clear lens with a coloured lens. The owners of the tug and barge maintained an inventory of these lanterns and used them from time to time on barges, as temporary sidelights, despite their visibility range being significantly below the requirement of three miles, which was set for safety purposes. To help ensure that only navigation lights that meet regulatory requirements are used by owners/masters of vessels, the regulations call for proof of compliance, be it in the form of documentation or a label.[4] Consequently, the industry, including the owners of the tug and tow, ought to have been aware that lights meeting regulatory requirements are available on the market and must be carried on board all tugs and tows. Approval from TC had not been received to permit Scotty lanterns to be used as a substitute for navigation lights required by regulations. The Scotty lanterns sold by manufacturers did not carry a proof of compliance document or label. In this instance, the navigation lights, including a spare set (oil lanterns), were carried by the tug. Further, unmanned barges such as Texada B.C. are not subject to inspection by TC. As such the onus is on the owners/masters to ensure that navigation lights used on barges meet the prescribed safety range requirement and carry proof of compliance document or label. Given the long history of the use of these navigation lights within the industry, and given that these lights are supplied by the company for use as navigation lights, the ship's complement had no reason not to accept them as such. Consequently, the risk associated with the use of these lights was unrecognized and the safety threshold was thus lowered. Reason's model of accident causation is used to illustrate, from a systemic perspective, a number of safety defences that had been breached. The result is the widespread use of lights for navigation purposes that do not meet the safety range of visibility (see Figure 1). Figure 1 Factors influencing the industry-wide use of lights for navigating with poor range of visibility (after Reason's model of organizational failure) In 1988, TC issued SSB 13/88, which cautioned industry participants to use navigation lights that conform with international standards. Further, in SSB 3/96, TC advised owners and operators who were unclear as to the requirements for navigation lights to contact a TCMS office. Nevertheless, the use of substandard navigation lights continues. 2.3 Effect of Background Lighting An observation of the view that would have been seen from the flying bridge of the Sunboy, as it made its way between its West Vancouver moorage and Burrard Inlet, was carried out on the night of August 11 (the next fireworks night). The observation revealed that from the command bridge one could see, from left to right, the north shore of Burrard Inlet, buoy QB, the unlit area of Stanley Park, a large group of boats assembled around the fireworks barge and, behind them, the shore lights along English Bay beach towards False Creek. As the Texada B.C. and the Sunboy were on a near-collision course, the bearing of the barge from the Sunboy would have remained constant. Hence, the predominately dark barge moving in front of Stanley Park would have been difficult to discern. Given the visibility range of the barge's starboard sidelight, the sighting of the barge from the Sunboy would have been made all the more difficult. This is consistent with the operator's perception that the barge was an island. Photo 6View from the area of the accident looking east. On the right is Stanley Park, which offers a dark background at night. 2.4 Proficiency of Pleasure Craft Operators 2.4.1 Sunboy Safe vessel operation depends on an operator's experience in applying sound navigational principles. In this instance, the operator of the Sunboy had received no formal nautical training. His training was limited to a three-hour vessel-familiarization briefing provided by two representatives of the agency from which he had purchased the vessel, in July 1997. The operator's inability to recognize the tug's navigational lights contributed to the pleasure craft passing astern of the tug and onto the cable of the towing bridle. The operator's knowledge of navigational practices, which would include COLREGS, was limited and is reflected in the following: he did not use appropriate nautical charts despite being unfamiliar with Burrard Inlet; his method of navigation was to follow other vessels ahead of him; he did not carry nautical publications that could have provided valuable navigational information; he elected to position himself on the command bridge while operating in the vicinity of heavy traffic. The absence of radar at this location precluded its use for navigation and collision avoidance, and limited the cues available to the operator; and he was unable to recognize the tug/tow navigation lights. 2.4.2 Domestic and Foreign Regulations In the USA, regulation of pleasure craft operations is within the domain of individual states. The need for formal training of pleasure craft operators has been recognized by some states, but not by all. The State of Washington, where the Sunboy was licensed, does not require pleasure craft operators to demonstrate proficiency. A minimum level of skill and knowledge is required of those who operate an automobile or aircraft for recreational purposes, but no such requirement exists for the majority of pleasure boat operators. The need for formal training of pleasure craft operators has been recognized by the CCG and a number of states in the USA. The Competency of Operators of Pleasure Craft Regulations made pursuant to the Canada Shipping Act are intended to address this need. The Regulations came into effect on 1 April 1999. While initially targeted at young boaters, by September 2009 the Regulations will extend to all Canadian operators of pleasure craft. With respect to foreign flag pleasure craft, although a certificate or similar document issued by an operator's state or country is accepted as proof of competency, the Regulations apply only to those pleasure craft that have remained in Canada 45 days or longer. As such, the Regulations do not apply to the majority of foreign operators of pleasure craft in Canada, whose visits are typically shorter than a month and a half. Hence, many foreign pleasure craft will continue to operate in Canadian waters for up to 45 days without their operators having met a proficiency requirement. As these pleasure craft operators have a potentially limited knowledge of COLREGS, the absence of a proficiency requirement increases the risk of marine accidents. 2.4.3 Navigation Light Recognition in CCG-accredited Courses CCG-accredited courses are designed to teach basic boating safety and are targeted at operators of pleasure craft using visual navigation. While these courses are required to include a review of the COLREGS, they do not impart a comprehensive knowledge of navigation lights fitted aboard commonly encountered commercial vessels such as tugs, barges, commercial fishing vessels and dredges. The lack of such knowledge has the potential to compromise safety, in that the danger associated with passing between a tug and tow, or between a fishing vessel and its fishing gear, or navigating into the path of an encumbered vessel is not recognized. Hence, a large number of pleasure craft operators plying Canadian waters may not be aware of these risks. 2.5 Operational Decisions Jose Narvaez Several publications are available to the mariner for navigational watchkeeping guidance. These include the COLREGS, the TC publication Recommended Code of Nautical Procedures and Practices, 1985 (TP 1018), and the International Chamber of Shipping publication Bridge Procedures Guide. Among other requirements, these publications, together with the owner's Master Standing Orders provide guidance in passage planning, determining the composition of the bridge watch and, in particular, the need for maintaining a proper lookout. As part of his passage plan, the master was required to consider the most appropriate method of towing a loaded barge, at night, through a part of the harbour where he could expect to encounter more pleasure craft than normal. The owners and the master of the tug were aware of the high level of pleasure craft traffic in Burrard Inlet and had readily available access to communication with each other through cellular telephone, but made no additional arrangement to ensure a safe passage, either before the night of the occurrence or at the time of sailing. The following factors highlight the absence of safety-oriented decisions including those made by the master while the tug and barge were being operated in an area of increased pleasure craft traffic: The starboard navigation light on the barge was known to be defective for a period of about 48 hours, during which period the barge was in port. Also, the intercom was defective for a period of time. However, the master did not inform the shore engineer that equipment which was essential for safe navigation of the tug/barge unit was defective. A large number of pleasure craft was known to be operating in the general area, including open boats with no provision to affix a radar reflector, which made their detection on the radar difficult. However, no dedicated lookout was posted. No escort vessel had been requested for this transit. At no time was a searchlight trained on the barge to highlight the danger.[5] No safety message prefixed SECURIT was broadcast to warn other vessels in the area of the approaching tug and barge. The on-watch deckhand was allowed to proceed below decks while the vessel was in an area of heavy traffic. The wheelhouse was temporarily left unattended at a critical time in the transit while the tug was being steered by automatic pilot. No vessel was targeted for close monitoring. 2.6 Company Operating Practices Jose Narvaez An effective long-term safety management system would foster continuous improvement in safety awareness and safety management skills and would provide a method of identifying and addressing non-conformities (be they compliance with a regulatory regime, or the company's policies, practices, and instructions). The International Maritime Organization (IMO) has recognized the merit of such an approach and, in 1993, adopted the International Safety Management (ISM) Code as a best practice for SOLAS (International Convention for the Safety of Life at Sea) vessels. Neither the Jose Narvaez nor the Texada B.C. are SOLAS vessels. As such, their owners are not required to develop a safety management system based on the ISM Code. However, the company has a safety management system in place. But because it is not effectively monitored, it does not achieve its stated objective. The safety documentation provided during the investigation, entitled Master Standing Orders, outlines the company's policy for shipboard and shore-based personnel. The policy places the responsibility for safe operation of the tug on the master, but there is no method identified to monitor the effectiveness of safe operational practices.[6] The reporting of deficiencies and the repairing and replacement of equipment has a direct impact on the ongoing safe operational performance of a vessel. The company's operating policy took a long-term approach to operating performance, assuring the quality of the way in which its business is conducted, and assuring the safety of its employees. Nevertheless, the following safety-related shortcomings were identified: Although the company's instructions to the vessel called for the OOW to ensure that proper navigational lights were up and working properly, the company supplied, as a common practice, improvised substandard navigation lights [Scottylanterns] for use as temporary navigation lights. The shortcoming with respect to the absence of guidance to tug/barge crew on the loading or securing of barges identified in Finding 13 of TSB Report No. M95W0095 to date remains unaddressed in the Master Standing Orders. [7] Vessel and company record-keeping were not adequate, in that equipment deficiencies were not recorded in the ship's log nor were written records kept of the equipment that had been repaired ashore and returned to the vessel. In fact, the documentation was not retained after the item was returned to the vessel. For some two and a half months prior to the occurrence, no safety meetings were recorded or held. Of those recorded safety meetings between 18 February 1999 and 24 May 1999, the entries were related to housekeeping matters and not related to the operational safety of the vessel. The company was aware of the higher-than-normal risk associated with a tug and tow operating in the vicinity of high-density pleasure craft traffic during special events in Vancouver harbour. Nevertheless, the company neither provided guidelines to the master nor initiated additional safeguards that would have helped ensure the voyage could be completed safely. 2.7 Event Planning and Traffic Management The Vancouver Harbour Master's office (HMO) plays a central role in the safe management of commercial and recreational marine traffic. In this instance, the HMO permitted the simultaneous operation__during the fireworks display __of commercial vessels and large numbers of pleasure craft. To enhance safety in these circumstances, the HMO office contacted the MCTS Vancouver Regional Marine Information Centre for the promulgation of a Notice to Shipping, engaged vessels to control traffic at the fireworks site, and made limited provision of escorts for commercial vessels passing through First Narrows. 2.7.1 Risk Assessment/Acknowledgement The movement of commercial traffic through the harbour at the time of the fireworks presented a risk that was noted, on the day of the occurrence. The HM Notice to Shipping warned of heavy congestion in the area and advised mariners to exercise caution and remain clear of this traffic where possible. Traffic Patterns and Traffic Control Measures In Burrard Inlet, pleasure craft and commercial vessels cross paths over a wide area. During the fireworks display, many pleasure craft from yacht clubs and marinas on the north shore of Burrard Inlet pass across the paths of commercial vessels. In the inner harbour, the movement of both commercial and pleasure craft traffic is generally east and west (with some traffic crossing the harbour to loading and docking facilities on both the north and south shores). Upon completion of the fireworks display in the outer harbour (Burrard Inlet), a large number of pleasure craft head towards First Narrows, and thence the inner harbour. Given that some 1,000 to 1,200 pleasure craft depart from a congregation point, it is difficult to facilitate an orderly flow of traffic. There are a number of traffic control measures that may help ensure that commercial traffic can safely traverse the area, unimpeded by pleasure craft. These include: controlling the flow of pleasure craft to and from the fireworks site, using vessels to direct pleasure craft traffic on site, and the establishment of corridors for traffic movement, possibly through the deployment of vessels stationed at intervals and/or the use of floating aids, etc. Vessels that are deemed to pose a high risk (either to human life, in the case of large cruise ships, or to the environment, in the case of tankers) are routinely escorted through First Narrows. The need to escort these vessels is acknowledged in the Port of Vancouver Harbour Operations Manual, and in the fireworks event plan. A tug with a tow is not considered a high risk vessel by either of these criteria, and does not receive an escort as a matter of course. Prior to the fireworks display, the Jose Narvaez was outbound and west of First Narrows. Neither the company nor the master of the Jose Narvaez requested an escort vessel, nor was one provided by the Vancouver Port Authority. At about the same time, a container vessel, which was inbound to Vancouver harbour, had requested an escort but none was available. On August 7, one vessel was available as an escort vessel during the early evening hours for a limited time (up to 2030). After the fireworks display, there were three commercial vessels outbound and approaching First Narrows between about 2320 and 2400. None of these vessels were escorted. Given that the pleasure craft crossing Burrard Inlet proceed across the commercial traffic lanes, the provision of escort vessels to keep pleasure craft from impeding the transit of commercial vessels in the given circumstances, especially at night, could have provided the commercial vessels with a greater measure of safety. This view has already been acknowledged: four days after the occurrence, on another evening of fireworks, two vessels were provided to escort inbound the 199-m-long general cargo vessel Star Hosanger (33,364 gross tonnage) through First Narrows. Amid pleasure craft, at night, tugs with tows pose a higher risk than do other vessels. A tow line can vary substantially in length and, as it is under water, it is not visible. Many pleasure craft operators have limited knowledge of the COLREGS, and so are unable to interpret the navigation lights displayed by tugs with tows. During fireworks events, this risk is further heightened by the presence of pleasure craft operators who are relatively unfamiliar with nighttime navigation. The risk associated with a tug and tow (or other hampered commercial vessel) was not fully recognized in the event plan. 2.7.2 Risk Management On the evening of the occurrence some 10 vessels, of various types, were engaged in the task of patrolling English Bay, where the majority of pleasure craft had gathered. The primary task of these vessels was to keep pleasure craft a safe distance from the fireworks barge, and to inspect pleasure craft for the presence of proper life-saving equipment. However, there is also a high risk of an accident occurring when a large number of pleasure craft are operating in the same area as commercial vessels. By focussing the patrols in the area of the fireworks display barge, commercial vessels transiting the Burrard Inlet and entrance to the inner harbour were exposed to high risk. The high risk associated with the transit of commercial vessels has not been fully addressed. 2.8 Emergency Response Timely notification of agencies is essential for prompt and efficient deployment of all resources and is critical to the success of a SAR mission. In this instance, there was a time lag in involving the West Vancouver fire department stationed a short distance away from the Fisheries Research Dock. As a result, during this occurrence the resources closest at hand were not dispatched by the EHS in a timely manner, although this had no detrimental effect on the success of the rescue. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The Sunboy operator's knowledge and understanding of navigational practices was such that he did not fully recognize navigational cues that posed a danger to his vessel. The Sunboy was navigated between the tug and the barge, struck by the barge and capsized, resulting in the loss of five lives. The navigational practices on board the Jose Narvaez--especially that of leaving the tug's wheelhouse unattended__resulted in the crew being unaware of the presence of the Sunboy at a critical time during the passage. The intercom on the bridge of the Jose Narvaez was not working at the time of the occurrence, leading the master of the tug to go below decks to find the on-watch deckhand. The absence of an effective side light, with a range of visibility of 3 nm, on the barge Texada B.C. deprived the operator of the Sunboy of a vital collision-avoidance cue to the presence and location of the barge. 3.2 Findings as to Risk The risk of a collision is increased by the use within the West Coast marine towing industry of temporary side lights that do not have the prescribed range of visibility. In contrast to the tug company's safety policy, its safety management system was not effectively monitored to achieve its objective. The lack of marine navigational knowledge on the part of pleasure craft operators poses undue risk when they are operating in waters shared with commercial traffic. Training on the identification of light configurations on commonly encountered commercial vessels is not a requirement of CCG-approved navigation courses for pleasure craft operators. Such identification can be critical to the safe operation of pleasure craft near commercial traffic. The State of Washington does not require operators of pleasure craft such as the Sunboy to have a minimum level of proficiency. Canadian regulations allow visiting operators of pleasure craft to ply Canadian waters without any navigational training, except where their stay exceeds 44 consecutive days. The transit of many pleasure craft and commercial vessels during fireworks evenings in Vancouver harbour results in situations where there is a high risk of collision--risk that has not been fully addressed by the precautions taken. 3.3 Other Findings EHS personnel did not notify the closest first-response agencies of the accident in a timely manner (although this had no detrimental effect on the success of this rescue). 4.0 Safety Action 4.1 Action Taken 4.1.1 Inadequacy of Navigation Lights In January 2000, the TSB sent Marine Safety Advisory (MSA) 04/00 to Transport Canada (TC). The Advisory expressed that, notwithstanding the issuance of Ship Safety Bulletin (SSB) 3/96,[8] navigation light deficiencies persist along with an accompanying loss of life and that TC may wish to initiate additional measures to ensure navigation lights carried aboard vessels, in particular tugs and tows, have ranges of visibility which minimize the risk of collision. TC has advised, by letter, the Council of Marine Carriers in British Columbia of the importance of having towing-related vessels display navigation lights that conform with the International Regulations for Preventing Collisions at Sea, 1972 (COLREGS) requirements for intensity, range and arc of visibility. TC sent copies of that letter to the Workers' Compensation Board of British Columbia, the B.C. Maritime Employers Association, the editors of the publications West Coast Mariner and Harbour Shipping, and all TC Pacific marine inspectors. On 23 June 2000, TC issued SSB 09/2000, entitled Navigation Lights and Ranges of Visibility. The Bulletin refers to COLREGS, and reminds shipowners, agents, vessel operators and, in particular, masters of vessels towing or pushing non-propelled vessels that the towed and pushed vessels are required to exhibit the prescribed navigation lights. It highlights that tests conducted on battery-operated lights such as Scotty lanterns manufactured by Scott Plastics Ltd. of Victoria, B.C., and kerosene/oil lanterns indicated a marked decrease in range of visibility. It stipulates that: not all of these lights may be marketed or manufactured for the purpose of navigation lights meeting the requirements of the COLREGS; mariners should ensure that the navigation lights used are in fact designed and manufactured for that purpose; and non-compliance may result in detention of the vessel and fines imposed. Canadian industry has worked with Transport Canada to produce a portable navigation light acceptable for use on barges. Two major barge-towing companies on the West Coast are working to obtain Transport Canada approval for a portable barge navigation light approved by the United States Coast Guard. 4.1.2 Celebration of Light Event Plan The search and rescue (SAR) operation order for the Celebration of Light (formerly Symphony of Fire) event is reviewed and updated annually. On 15 June 2001, Rescue Co-ordination Centre (RCC) Victoria issued SAR Operation Order 2001 Celebration of Light intended to protect the public and the Celebration of Light employees. The components of the Order include both SAR operations and event contingency planning. RCC Victoria is responsible for SAR response; the Vancouver Port Authority is responsible for overall safe operation of the harbour and provides clearance to commercial vessels to enter the harbour. The plan is a joint effort and was produced following meetings with all interested parties. In keeping with the local Incident Command Structure, meetings were chaired by the Harbour Master and the final RCC Victoria SAR Operation Order 2001 Celebration of Light document was agreed to by the Harbour Master and all concerned. The command and control of the SAR Order falls under the auspices of the Commander, Maritime Forces Pacific, who has responsibility for SAR in the area, and any amendments would be issued by the Officer-in-Charge at RCC Victoria. Emergency Health Services (EHS) personnel would be available on one of the support vessels and a list of evacuation locations, descriptions and contact numbers would be available. Other support services identified include Marine communications and Traffic Services (MCTS), the Pacific Weather Centre, Public Affairs, Canadian Coast Guard (CCG) marine resources, and Department of National Defence air resources. Also, police, fire, amateur radio, ambulance, sailing clubs and the Vancouver Parks Board would assist. A safety issue identified in this accident report was the risk of collision associated with commercial vessels and a high density of pleasure craft in the same area. Under the SAR Order, commercial traffic would be assisted by a Port Authority vessel in the First Narrows area. Further, to help ensure the safe transit of both commercial vessels and pleasure craft in Burrard Inlet, escort vessels are strategically positioned, at the periphery of the pleasure craft congregation area, to keep pleasure craft from impeding the passage of commercial vessels. The Board believes that these measures will further transportation safety by mitigating some of the risks associated with special events. However, the impact of these changes on safety cannot be fully determined at this stage--continuing evaluation of the plan is encouraged. The Board noted that in situations where there is a larger-than-usual volume of pleasure craft operating near commercial traffic, there is an elevated risk of collision. This is compounded by the fact that pleasure craft operators may be operating their vessels without adequate navigational knowledge. Over-water displays are also held at a number of other Canadian ports, including Halifax, Qubec, Montral, Toronto and Windsor. These ports have in place plans and procedures to reduce this risk. In light of this occurrence, and given the dynamic nature of these special events, the Board further encourages those responsible for organizing and coordinating special events to periodically review their arrangements and contingencies to identify and mitigate newly arising risks. To this end, the Board has communicated this concern to the various responsible organizations across Canada, through targeted distribution of a marine safety information letter, and of the final report of this investigation. 4.1.3 MCTS Following the occurrence, MCTS reviewed its Vancouver operations' procedures, training and equipment efficiency. The following recommendations made to CCG management, to optimize MCTS Centre performance, have been implemented: Standards and procedures have been reviewed and amended accordingly at both the local and national levels to ensure consistency and provide further clarification to operational staff. A new Vancouver Centre Operations Information Manual has been created to incorporate the revised local/national standards, replacing the old manuals in the operations room. Training needs have been reviewed and provided as required, including Distress Refresher training, to operational personnel on a cyclical basis. Equipment has been upgraded to better address operational needs. 4.1.4 CCG The CCG, aware that the absence of knowledge on the identification of light configurations on tugs increases the risk of marine accidents, has introduced the following safety information message in its 2001 edition of the Safe Boating Guide: Tugs may be towing barges or other ships on a long tow-line astern. Often, the length of the tow is so great that the towline hangs below the surface of the water and is virtually invisible. If a small vessel strikes the submerged towline it could capsize and then be run down by the barge. Never pass between a tug and its tow and make sure that you are aware of the special lights displayed by tugs towing barges or other vessels or objects. This guide is distributed free of charge and is also available on the CCG Web site. In addition, the CCG has formed working groups to assess the Operator Competency Program and will make recommendations for improving the implementation of the program. This could result in a review of the CCG Boating Safety Course Standard for the inclusion of more COLREGS knowledge for boaters. 4.1.5 Lafarge Canada Inc. Corporate safety initiatives applicable to the marine arm, in place since 1999, are as follows: the formation of a North American Lafarge safety council the issuance of a North American safety policy by the President the publication of a North American Lafarge safety manual, and monthly reporting from each operation. 4.2 Safety Action Required 4.2.1 Continued Use of Substandard Navigation Lights on Barges and Booms The Board noted the safety action taken by the industry to make available portable navigation lights meeting the regulatory requirement. However, the Board is concerned that although navigation lights meeting the safety visibility range are available on the market, substandard navigation lights continue to be used by the towing industry. There is no system in place, either regulatory or through an industry initiative, to ensure the use of lights that meet the safety range prescribed in the COLREGS.[9] Currently, unmanned barges are not subject to inspection by Transport Canada, Marine Safety, and the onus is on the owner/operator of the vessel to ensure that proper navigation lights are used. Navigation lights that meet the prescribed range of visibility are available, the risks associated with the use of substandard lights have been identified, and steps have been taken to address this safety issue. Nevertheless, the use of such lights continues, and with it the attendant risk of collisions. The Board, therefore, recommends that: The Department of Transport, in collaboration with the Council of Marine Carriers and other industry representatives, ensure that tugs and tows are equipped with navigation lights that meet the safety range of visibility. 4.2.2 Pleasure Craft Operator Competency Both Canada and the United States have recognized the need for proficiency of pleasure craft operators. The lack of adequate navigational knowledge has been identified as a factor in a number of TSB marine accident reports involving small vessel operators, be they on fishing vessels or on recreational craft. The CCG Office of Boating Safety introduced the Canadian Operators of Pleasure Craft Regulations in April 1999 to mitigate risks in pleasure boating. While initially targeted at young boaters, the regulations will not extend to all Canadian pleasure craft operators until September 2009. This will result in the continued presence of pleasure craft crewed by untrained pleasure craft operators in Canada. However, a review of the CCG-accredited training courses revealed that they do not impart comprehensive knowledge of navigation lights fitted aboard commonly encountered commercial vessels such as tugs, tows, fishing vessels, etc. Such identification is critical to the safe operation of pleasure craft, particularly in areas regularly used by commercial traffic. The CCG has formed working groups to assess the operator competency program and recommendations are expected that could result in a review of the CCG Boating Safety Course Standard. In the United States, the National Transportation Safety Board (NTSB), the United States Coast Guard, and the National Association of State Boating Law Administrators have recognized the risks associated with inadequate competency of pleasure craft operators. NTSB recommendations M-93-01 and M-93-14 recommend to the governors and legislative leaders of the 50 states, and the National Association of State Boating Law Administrators, the implementation of minimum recreational boating safety standards, including demonstration of operator knowledge of safe boating rules and skills, and operator licensing. A number of states have recognized the need for, and implemented, operator training and proficiency requirements. However, the State of Washington does not require operators of pleasure craft like the Sunboy to have a minimum level of proficiency. Provisions in the Canadian regulations allow visiting operators of foreign pleasure craft (mostly from the United States, including the State of Washington) to ply Canadian waters without such training, except where their stay in Canada exceeds 44consecutive days. Similarly, provisions in the United States regulations allow Canadian operators up to 59 consecutive days without navigational training. However, operators pose a greater risk during their initial period in foreign waters, being unfamiliar with the area, routines and practices. By these provisions, boaters who may be without adequate safety training and navigational skills are allowed to operate side by side with commercial traffic. Untrained pleasure craft operators will continue to pose a risk to the marine environment, given the implementation time frame for the certification of Canadian pleasure craft operators and the cross-border provisions in the regulations. The Board believes that additional measures are warranted to reduce the risk__both to pleasure boaters and commercial traffic__of the current situation, which allows untrained personnel to operate pleasure craft. The Board, therefore, recommends that: The Department of Fisheries and Oceans, in conjunction with the appropriate authorities in the United States, explore ways to ensure that operators of pleasure craft in their respective jurisdictions possess adequate competency and basic knowledge of navigation safety, including the requirements of the International Regulations for Preventing Collisions at Sea.